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\author{med\_panda}
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  /Title (abdominal-ippa.pdf)
  /Creator (Cheatography)
  /Author (med\_panda)
  /Subject (Abdominal IPPA Cheat Sheet)
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        \hspace*{-6pt}\includegraphics[width=5.8cm]{/web/www.cheatography.com/public/images/cheatography_logo.pdf}}
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\begin{tabulary}{11cm}{L}
    \vspace{-2pt}\large{\bf{\textcolor{DarkBackground}{\textrm{Abdominal IPPA Cheat Sheet}}}} \\
    \normalsize{by \textcolor{DarkBackground}{med\_panda} via \textcolor{DarkBackground}{\uline{cheatography.com/184394/cs/39954/}}}
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  \mymulticolumn{2}{p{5.377cm}}{\bf\textcolor{white}{Cheatographer}}  \\
  \vspace{-2pt}med\_panda \\
  \uline{cheatography.com/med-panda} \\
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  \mymulticolumn{1}{p{5.377cm}}{\bf\textcolor{white}{Cheat Sheet}}  \\
   \vspace{-2pt}Not Yet Published.\\
   Updated 21st August, 2023.\\
   Page {\thepage} of \pageref{LastPage}.
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  Measure your website readability!\\
  www.readability-score.com
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\begin{document}
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\begin{multicols*}{2}

\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{Introduction}}  \tn
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{- Ensure that the room is well lit, \newline % Row Count 1 (+ 1)
- Patient should have an empty bladder \newline % Row Count 2 (+ 1)
- Make patient comfortable in a supine position, with a pillow for the head and if available, another pillow under the knees.  \newline % Row Count 5 (+ 3)
- Have the patient keep arms at the sides \newline % Row Count 6 (+ 1)
- If abdomen is voluntarily rigid, can flex at hip and knee to relax abdominal muscles \newline % Row Count 8 (+ 2)
- For a child: if uncomfortable place on caregiver's lap as long as abdomen is flat \newline % Row Count 10 (+ 2)
- Full exposure of the abdomen (from above the xiphoid process to the symphysis pubis). The groin should be visible. The genitalia should be covered. \newline % Row Count 13 (+ 3)
- Ask the patient if they are experiencing any pain anywhere% Row Count 15 (+ 2)
} \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{You can even slide your hand under the low back to see if the patient is relaxed and flat on the table. Putting a pillow under the knees and allowing the patient to bend their knees so that the soles of their feet rest on the table will also relax the abdomen. \newline When the patient raises their arms over their heads, it stretches and tightens the abdominal wall, making palpation difficult \newline  \newline The abdominal muscles should be relaxed for all parts of the examination, but especially for palpation}  \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{Inspection}}  \tn
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{- Standing at the right-hand side of the bed, inspect the abdomen. Bend down or look from the side if needed \newline % Row Count 3 (+ 3)
- Look at the contours of the abdomen - Is the abdomen of normal contour/fullness, or is it distended? Is it scaphoid (sunken)? Comment on this. \newline % Row Count 6 (+ 3)
- Generalized fullness or distension fat, fluid, flatus, feces, fetus or fulminant mass. \newline % Row Count 8 (+ 2)
- Localized distension may be symmetrical, or asymmetrical \newline % Row Count 10 (+ 2)
- Scaphoid abdomen in advanced stages of starvation and malignant disease \newline % Row Count 12 (+ 2)
- Peristalsis - Observe for several minutes (especially if you suspect intestinal obstruction). Peristalsis may be visible normally in very thin people but again, it usually suggests intestinal obstruction \newline % Row Count 17 (+ 5)
- Pulsations -  may be visible. An expanding central pulsation in the epigastrium suggests an abdominal aortic aneurysm. However, the abdominal aorta can often be seen to pulsate in normal thin people \newline % Row Count 22 (+ 5)
- Inspect the skin over the abdomen, mentioning the presence \newline % Row Count 24 (+ 2)
    of any: \newline % Row Count 25 (+ 1)
Scars - Describe or outline their location. \newline % Row Count 26 (+ 1)
Striae - Old brownish red striae or stretch marks \newline % Row Count 27 (+ 1)
Dilated veins - A few small veins may be visible normally. \newline % Row Count 29 (+ 2)
Rashes and lesions, discolorations \newline % Row Count 30 (+ 1)
} \tn 
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{Inspection (cont)}}  \tn
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{-  Observe the umbilicus - Observe its contour and location, and any signs of inflammation or hernia. The umbilicus is normally slightly retracted and inverted.% Row Count 4 (+ 4)
} \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{Local swellings may indicate enlargement of one of the abdominal or pelvic organs}  \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
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\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{Auscultation}}  \tn
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{ASSESS FOR BOWEL SOUNDS: \newline % Row Count 1 (+ 1)
- Listen for bowel sounds and note their frequency and quality/character.  \newline % Row Count 3 (+ 2)
- Normal sounds consist of clicks and gurgles, occurring at an estimated frequency of 5 - 34 per minute.  \newline % Row Count 6 (+ 3)
- Tinkling bowel sounds - typically associated with bowel obstruction. \newline % Row Count 8 (+ 2)
- Absent bowel sounds - suggests ileus (a disruption of the normal propulsive ability of the intestine). Causes of ileus include electrolyte abnormalities and recent abdominal surgery.  \newline % Row Count 12 (+ 4)
LISTEN FOR BRUITS: \newline % Row Count 13 (+ 1)
- Auscultate over the aorta and renal arteries to identify vascular bruits suggestive of turbulent blood flow: \newline % Row Count 16 (+ 3)
- Aortic bruits: auscultate 1-2 cm superior to the umbilicus, a bruit here may be due to an abdominal aortic aneurysm. \newline % Row Count 19 (+ 3)
- Renal bruits: auscultate 1-2 cm superior to the umbilicus and slightly lateral to the midline on each side. A bruit here may be due to renal artery stenosis.% Row Count 23 (+ 4)
} \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{To be able to confidently state that a patient has 'absent bowel sounds' you need to auscultate for at least 3-5 minutes (this is unlikely to be done in an OSCE given the time limitations). \newline A bruit is an abnormal blowing or swishing sound resulting from blood flowing through a narrow or partially occluded artery \newline For now, just focus on listening for bruit over the aorta and renal arteries}  \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
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\begin{tabularx}{8.4cm}{X}
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\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{Percussion}}  \tn
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{Sounds heard on percussion over the abdomen: \newline % Row Count 1 (+ 1)
1) Tympany (drum-like) sounds – produced by percussing over air filled structures \newline % Row Count 3 (+ 2)
2) Dull sounds – occur when a solid structure (e.g. liver) or fluid (e.g. ascites) lies beneath the region being examined% Row Count 6 (+ 3)
} \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{Special note should be made if percussion produces pain, which may occur if there is underlying inflammation (E.g.: peritonitis). This would be supported by other history and physical exam findings.}  \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
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\begin{tabularx}{8.4cm}{X}
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\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{Palpation}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{} \tn 
% Row Count 0 (+ 0)
\hhline{>{\arrayrulecolor{DarkBackground}}-}
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\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{Superficial}}  \tn
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{- Keep your hand and forearm on the same horizontal plane, with fingers together and flat on the abdominal surface – even if this means bending down or kneeling by the patient's side.  \newline % Row Count 4 (+ 4)
- Palpate the abdomen with a gentle but firm motion. Mould the relaxed right hand to the abdominal wall, do not to hold it rigid. When moving your hand from place to place, raise it just off the skin.  \newline % Row Count 9 (+ 5)
- Lightly palpate each of the four quadrants or nine abdominal regions \newline % Row Count 11 (+ 2)
- Identify any superficial organs or masses and any area of tenderness or increased resistance (guarding) to your hand \newline % Row Count 14 (+ 3)
SEE IF SUPERFICIAL PALPATION ELICITS  \newline % Row Count 15 (+ 1)
ANY OF THE FOLLOWING: \newline % Row Count 16 (+ 1)
- Voluntary guarding - contraction of the abdominal muscles in response to pain \newline % Row Count 18 (+ 2)
- Involuntary guarding/rigidity - involuntary tension in the abdominal muscles that occurs on palpation associated with peritonitis (e.g. appendicitis, diverticulitis) \newline % Row Count 22 (+ 4)
- Masses - large or superficial masses may be noted on light palpation. \newline % Row Count 24 (+ 2)
-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}-{}- \newline % Row Count 26 (+ 2)
Tenderness is an important sign and maybe associated with guarding.  \newline % Row Count 28 (+ 2)
Try to distinguish between voluntary guarding (conscious contraction or tensing of the abdominal muscles in anxious patients anticipating a potentially painful clinical examination) and involuntary guarding (muscular spasm or rigidity due to localized peritoneal inflammation causing reflex contraction of overlying abdominal muscles upon palpation) \newline % Row Count 36 (+ 8)
} \tn 
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{Superficial (cont)}}  \tn
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{Differentiating between voluntary and involuntary guarding can be done by talking to the patient to divert their attention whilst palpating, which would reduce voluntary but not involuntary guarding.% Row Count 5 (+ 5)
} \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\bf{Rebound Tenderness}} \newline Pain that occurs upon the rapid removal of pressure rather than on application of pressure. Due to appendicitis, peritonitis, etc.  Also known as 'Blumberg Sign' \newline {\bf{Rovsing's Sign}} \newline When deep palpation in the left iliac fossa causes pain in the right iliac fossa Indirect or referred tenderness}  \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{Deep}}  \tn
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{- Deep palpation of the abdomen is performed by placing the flat of the hand on the abdominal wall and applying firm, steady pressure. It may be helpful to use two-handed/bimanual palpation method, particularly in evaluating a mass.  \newline % Row Count 5 (+ 5)
- Here the upper hand is used to exert pressure, while the lower hand is used to feel. \newline % Row Count 7 (+ 2)
- Palpate each of the nine abdominal regions again, this time applying greater pressure to identify any deeper masses. \newline % Row Count 10 (+ 3)
- If any masses are identified during deep palpation, assess the following characteristics: \newline % Row Count 12 (+ 2)
{\emph{Location}} - note which of the nine abdominal regions is the mass located in \newline % Row Count 14 (+ 2)
{\emph{Size and shape}} - assess approximate size and shape of the mass \newline % Row Count 16 (+ 2)
{\emph{Consistency:}} assess the consistency of the mass (e.g. smooth, soft, hard, irregular) \newline % Row Count 18 (+ 2)
{\emph{Mobility}} - assess if the mass appears to be attached to superficial or underlying structures \newline % Row Count 20 (+ 2)
{\emph{Pulsatility}} - note if the mass feels pulsatile, suggestive of vascular etiology (e.g. abdominal aortic aneurysm).% Row Count 23 (+ 3)
} \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{Inform the patient this may feel uncomfortable and ask them to let you know if they want you to stop.  \newline Carefully monitor the patient's face for any discomfort}  \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{Deep}}  \tn
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{- Deep palpation of the abdomen is performed by placing the flat of the hand on the abdominal wall and applying firm, steady pressure. It may be helpful to use two-handed/bimanual palpation method, particularly in evaluating a mass.  \newline % Row Count 5 (+ 5)
- Here the upper hand is used to exert pressure, while the lower hand is used to feel. \newline % Row Count 7 (+ 2)
- Palpate each of the nine abdominal regions again, this time applying greater pressure to identify any deeper masses. \newline % Row Count 10 (+ 3)
- If any masses are identified during deep palpation, assess the following characteristics: \newline % Row Count 12 (+ 2)
{\emph{Location}} - note which of the nine abdominal regions is the mass located in \newline % Row Count 14 (+ 2)
{\emph{Size and shape}} - assess approximate size and shape of the mass \newline % Row Count 16 (+ 2)
{\emph{Consistency:}} assess the consistency of the mass (e.g. smooth, soft, hard, irregular) \newline % Row Count 18 (+ 2)
{\emph{Mobility}} - assess if the mass appears to be attached to superficial or underlying structures \newline % Row Count 20 (+ 2)
{\emph{Pulsatility}} - note if the mass feels pulsatile, suggestive of vascular etiology (e.g. abdominal aortic aneurysm).% Row Count 23 (+ 3)
} \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{Inform the patient this may feel uncomfortable and ask them to let you know if they want you to stop.  \newline Carefully monitor the patient's face for any discomfort}  \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}


% That's all folks
\end{multicols*}

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